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Line Operations Safety Assessment (LOSA): Maintenance (Mx) Operations

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Title: Line Operations Safety Assessment (LOSA): Maintenance (Mx) Operations


1
Line Operations Safety Assessment (LOSA)
Maintenance (Mx) Operations Base Training
Scenarios
August 2013 (v5)
2
Observer Training Preparation
  • Prior to the start of this training
  • Install a free copy of the LOSA Database
    Software http//www.MRLOSA.com
  • Use the User ID and Password assigned by your
    LOSA Administrator to log in

3
Observation Forms
4
Mx Demographics form
5
Mx Threat Codes
6
General Guidelines
  • The form is a guide and a place to record data
    for later analysis
  • Do not need to observe everything on the forms
  • Observe and take samples of behaviors in the
    hangar or shop or on the ramp
  • The form is not in the spirit of a starting
    engine or pre-takeoff checklist
  • The observer as a Subject Matter Expert (SME)
    will probably notice threats and errors without
    needing the form as a cue
  • Take notes during observation then fill in the
    forms later

7
Observer Preparation
  • Take a few minutes before an observation to
    review the form
  • Make a general plan for your observations
  • Be open to changing your plan and look for the
    unexpected

8
Observation Example
9
Situation
  • The mechanic I was observing got to work at
    600 am that morning and started a 2 engine
    change procedure on a B757-200. After
    disconnecting the first quick disconnect line, he
    got paged and went to take a phone call from his
    wife. He came back and finished up disconnecting
    and capping the remaining quick disconnects, but
    he did not cap the first quick disconnect line.
    He signed the work card without noticing his
    error.
  • When answering the demographics questions, the
    mechanic stated that he was a midnight shift
    (1000 pm to 600 am) mechanic. He was called in
    to work the day shift on his second day off. On
    his first day off, he went bowling with his
    family until 1130 pm. He got the call to report
    at 600 am for the day shift after arriving back
    home around midnight.

10
(No Transcript)
11
Mx LOSA Observation Form Sections
  • A. Planning
  • B.1 Prepare for Removal
  • B.2 Removal
  • B.3 Prepare to Install
  • B.4 Install
  • B.5 Installation Test
  • B.6 Close-up/Complete Restore
  • C. Fault Isolation/Troubleshooting/Deferral
  • D. Servicing

12
LOSA Observation Form
13
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

14
Form Section B.2 Removal
  • Error At Risk item 12 REMOVAL PROCEDURES
    FOLLOWED
  • Threat codes
  • Individual Factors Mx/F2 (Fatigue), Mx/F8
    (Workplace distractions or interruptions during
    task performance), Mx/F15 (Other Technician
    worked on his regular day off).
  • Error At Risk item 18 INDIVIDUAL WORK STEPS
    SIGNOFF COMPLETED
  • Threat codes
  • Individual Factors Mx/F8 (Workplace distractions
    or interruptions during task performance)
  • Effectively managed? ? No
  • Error Outcomes ? Undesired state (uncapped quick
    disconnect line).

15
Mx/F. Individual Factors Mx/F1. Physical
health (including hearing and sight) Mx/F2.
Fatigue Mx/F3. Time pressure Mx/F4. Peer
pressure Mx/F5. Complacency Mx/F6. Body
size/strength Mx/F7. Personal event (e.g.,
family problem, car accident) Mx/F8.
Workplace distractions or interruptions during
task performance Mx/F9. Memory lapse
(forgot) Mx/F15. Other (Technician worked on
his regular day off
16
LOSA Observation Form
17
Additional Comments
When answering the demographics questions the
mechanic stated that he was a midnight shift
(1000 pm to 600 am) mechanic. He was called in
to work the day shift on his second day off. On
his first day off, he went bowling with his
family until 1130 pm. He got the call to report
for the day shift after arriving back home around
midnight.
The mechanic I was observing got to work at 600
am that morning and started a 2 engine change
procedure on a B757-200. After disconnecting the
first quick disconnect line, he got paged and
went to take a phone call from his wife. He came
back and finished up disconnecting and capping
the remaining quick disconnects, but he did not
cap the first quick disconnect line. He signed
the work card without noticing his error.
We all work fatigued but we need to be more
careful.
18
Practice Observations
19
Practice Observation Instructions
  • Complete the appropriate section of the
    observation form for each of the following
    scenarios.
  • Identify and mark down the threats and error
    outcomes and include any remarks.
  • Following your observation, enter your
    information into the Mx LOSA software database.

20
Scenario 1 Incorrect Tires
21
Situation
  • After a test flight following heavy
    maintenance, a 737-900 arrived late for its
    scheduled flight in 15 degree F (-9 C) weather.
    On a maintenance walk-around, the 1 tire (main
    landing gear) was completely deflated, which
    required both the 1 and 2 tires to be changed.
  • The technician had a limited amount of time
    to do the job and to get the aircraft turned
    around in time to meet the Estimated Time of
    Release. He installed the tires for a 737-900 ER
    on a 737-900. The two aircraft require different
    tires, although both tires look the same and will
    fit on either aircraft. The inspector found the
    mistake before the aircraft was returned to the
    line.

22
(No Transcript)
23
LOSA Observation Form
24
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

25
Errors and Threats
  • Error At Risk item 5 Effectivity/Configuration
    Verified.
  • Threat codes
  • Aircraft Design/Configuration/Parts Mx/C3
    (Aircraft configuration variability)
  • Error At Risk item 8 Installation procedures
    followed.
  • Threat codes
  • Aircraft Design/Configuration/Parts Mx/C6 (Easy
    to install incorrectly)
  • Environment/Facilities Mx/G3 (Environment/Facilit
    ies Cold)
  • Effectively managed? ? Yes
  • Error Outcomes ? Inconsequential

26
Mx/C. Aircraft Design / Configuration /
Parts Mx/C1. Complex Mx/C2.
Inaccessible Mx/C3. Aircraft configuration
variability Mx/C4. Parts unavailable Mx/C5.
Parts incorrectly labeled/certified Mx/C6.
Easy to install incorrectly Mx/C7. Parts not
used Mx/C8. Other (explain below)
27
Mx/G. Environment / Facilities Mx/G1. High
noise level Mx/G2. Hot Mx/G3. Cold Mx/G4.
Humidity Mx/G5. Rain Mx/G6. Snow Mx/G7.
Lightning
28
LOSA Observation Form
29
Additional Comments
After a post-heavy Mx test flight a 737-900
arrived late in 15 degree F (-9 C) weather. On a
maintenance walk-around, the 1 tire (main
landing gear) was completely deflated, which
required both 1 and 2 tires to be changed. The
technician had a limited amount of time to do the
job and to get the aircraft turned around in time
to meet the Estimated Time of Release (ETR).
He installed the tires for a 737-900 ER on a
737-900. The two aircraft require different
tires, although both tires look the same and will
fit on either aircraft.
The inspector found the mistake before the
aircraft was returned to the line. This is fine
but we need to find a way to reduce the chance of
this happening. The extra work and expense of
fixing the mistake probably cost more than some
solutions.
30
Scenario 2 Transducer Out of Rig
31
Situation
  • Two technicians replaced a 1 engine T/R
    inboard center drive unit (the CDU) on a
    B767-200. The LOSA observer overheard the manager
    say that the airplane needed to be ready in three
    and a half hours and there was another plane they
    needed to work after this one. The airplane was
    outside the hangar on a 100-degree F. (38 degree
    C.) sunny day. The LOSA observer also saw the
    technicians begin work without reviewing the
    procedure. Although they read the manual after
    beginning the task, the transducer was not rigged
    properly during the installation. The T/R
    subsequently failed the operational check.

32
(No Transcript)
33
LOSA Observation Form
34
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

35
Errors and Threats
  • Error At Risk item 8 INSTALLATION PROCEDURES
    FOLLOWED
  • Threat codes
  • Knowledge/Skills Mx/E6 (Task planning did not
    take enough time to go over the procedure)
  • Individual Factors Mx/F3 (Time pressure)
  • Environment/Facilities Mx/G2 (Hot)
  • Effectively managed? ? No
  • Error Outcomes ? Undesired state (improperly
    rigged transducer)

36
Mx/E. Knowledge / Skills Mx/E1. Technical
skills Mx/E2. Computer skills Mx/E3.
Teamwork skills Mx/E4. English
proficiency Mx/E5. Task knowledge Mx/E6.
Task planning Mx/E7. Company process
knowledge Mx/E8. Aircraft system
knowledge Mx/E9. Other (explain below)
37
Mx/F. Individual Factors Mx/F1. Physical
health (including hearing and sight) Mx/F2.
Fatigue Mx/F3. Time pressure Mx/F4. Peer
pressure Mx/F5. Complacency Mx/F6. Body
size/strength Mx/F7. Personal event (e.g.,
family problem, car accident) Mx/F8.
Workplace distractions or interruptions during
task performance Mx/F9. Memory lapse
(forgot)
38
Mx/G. Environment / Facilities Mx/G1. High
noise level Mx/G2. Hot Mx/G3. Cold Mx/G4.
Humidity Mx/G5. Rain Mx/G6. Snow Mx/G7.
Lightning
39
LOSA Observation Form
40
Additional Comments
Two technicians replaced a 1 engine T/R
inboard center drive unit (the CDU) on a
B767-200. The LOSA observer overheard the manager
say that the airplane needed to be ready in three
and a half hours and there was another plane they
needed to work after this one. The airplane was
outside the hangar on a 100-degree F. (38 degree
C.) sunny day. The LOSA observer also saw the
technicians begin work without reviewing the
procedure. Although they read the manual after
beginning the task, the transducer was not rigged
properly during the installation. The T/R
subsequently failed the operational check.
Although they read the manual the transducer was
not rigged properly during the installation. The
thrust reverser failed the ops check and needed
to be re-rigged.
38
41
Scenario 3 B737-500 Down-Jacking
42
Situation
  • Technicians were performing gear swing on a
    737-500. After completing the operational check,
    one of the technicians cleared the aircraft for
    down jacking. As the aircraft was being lowered,
    the LOSA observer realized a maintenance stand
    had not been removed from under the tail
    compartment access door, and stopped the down
    jacking. They removed the stand and continued
    lowering the aircraft.

43
(No Transcript)
44
LOSA Observation Form
42
45
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

46
Form Section B.6 Close Up/Complete Restore
  • Error At Risk item 11 Return to normal
    condition procedures followed
  • Threat codes
  • Individual Factors Mx/F13 (Situational
    Awareness)
  • Communication Mx/J4 (Maintenance crew and lead)
  • Effectively managed? ? No
  • Error Outcomes ? Undesired state (LOSA observer
    intervened due to imminent damage)

47
Mx/F. Individual Factors Mx/F1. Physical health
(including hearing and sight) Mx/F2. Fatigue Mx/F3
. Time pressure Mx/F4. Peer pressure Mx/F5. Compla
cency Mx/F6. Body size/strength Mx/F7. Personal
event (e.g., family problem, car
accident) Mx/F8. Workplace distractions or
interruptions during task performance Mx/F9. Memor
y lapse (forgot) Mx/F10. Visual
perception Mx/F11. Assertiveness Mx/F12. Stress Mx
/F13. Situational awareness Mx/F14. Not properly
dressed (e.g., for weather) Mx/F15. Other
(explain below)
48
Mx/J. Communication Mx/J1. Between
departments Mx/J2. Between mechanics Mx/J3.
Between shifts Mx/J4. Between maintenance crew
and lead Mx/J5. Between lead and
management Mx/J6. Between flight crew and
maintenance Mx/J7. Other (explain below)
49
LOSA Observation Form
47
50
Additional Comments
Technicians were performing gear swing on a
Boeing 737-500. After completing the ops check,
one of the technicians cleared the aircraft for
down jacking.
As the aircraft was being lowered, I realized a
Mx stand had not been removed from under the tail
compartment access door, and stopped the down
jacking. They removed the Mx stand and continued
the lowering the aircraft.
I had to intervene before they damaged the
aircraft. We need to take a closer look at what
went wrong.
51
Scenario 4 Improperly Pinned Slide
52
Situation
  • A senior mechanic with 24 years of experience
    was working a double shift following a trade
    day. He was installing a B737-500 aft entry door
    slide assembly. He did not use the maintenance
    manual, even though he was providing on-the-job
    training to two inexperienced technicians.
  • The R R was done under very poor lighting
    conditions. The mechanic forgot to remove the
    safety pin from the new slide raft after
    installation.
  • The QC inspector found that the pin was not
    removed from the installed slide.

53
(No Transcript)
54
LOSA Observation Form
55
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

56
Errors and Threats
  • Error At Risk item 8 INSTALLATION PROCEDURES
    FOLLOWED
  • Threat codes
  • Individual Factors Mx/F9 (Memory lapse forgot)
  • Environment/Facilities Mx/G8 (Illumination)
  • Organizational Factors Mx/H8 (Work
    process/procedure not followed)
  • Information Mx/A9 (Information not used)
  • Effectively managed? ? Yes (caught by QC
    inspector)
  • Error Outcomes ? Inconsequential

57
Mx/F. Individual Factors Mx/F1. Physical
health (including hearing and sight) Mx/F2.
Fatigue Mx/F3. Time pressure Mx/F4. Peer
pressure Mx/F5. Complacency Mx/F6. Body
size/strength Mx/F7. Personal event (e.g.,
family problem, car accident) Mx/F8.
Workplace distractions or interruptions during
task performance Mx/F9. Memory lapse
(forgot)
58
Mx/G. Environment / Facilities Mx/G1. High
noise level Mx/G2. Hot Mx/G3. Cold Mx/G4.
Humidity Mx/G5. Rain Mx/G6. Snow Mx/G7.
Lightning Mx/G8. Illumination
59
Mx/H. Organizational Factors Mx/H1. Quality
of internal support from technical
organizations Mx/H2. Quality of external
support from technical organizations Mx/H3.
Company policies Mx/H4. Not enough
staff Mx/H5. Corporate change /
restructuring Mx/H6. Labor action Mx/H7. Work
process / procedure Mx/H8. Work process /
procedure not followed
60
Mx/A. Information Mx/A1. Not
understandable Mx/A2. Unavailable or
inaccessible Mx/A3. Incorrect Mx/A4.
Inadequate (e.g., missing graphics) Mx/A5.
Uncontrolled (e.g., outdated) Mx/A6. Too much
conflicting information Mx/A7. Updated
process is too long or complicated Mx/A8.
Incorrectly modified manufacturers Maintenance
Manual/Service Bulletin Mx/A9. Information
not used Mx/A10. Other (explain below)
61
LOSA Observation Form

62
Additional Comments
I was observing a senior mechanic. He was
performing a B737-500 aft entry door slide
assembly install. He did not use the maintenance
manual, even though he was providing on-the-job
training to two inexperienced technicians. The
remove and replace task was done under very poor
lighting conditions. During the demographics
questions he stated he has 24 years of
experience. He was also working a double shift
following a trade day.
The mechanic did not remove the pin from the new
slide raft after installation. The QC
inspector found that the pin was not removed from
the installed slide.
63
This Concludes the Line Operations Safety
Assessment (LOSA) Maintenance (Mx) Operations
Base Training Scenarios
64
Line Operations Safety Assessment (LOSA)
Maintenance (Mx) Operations Line Training
Scenarios
February 2012 (v4)
65
Observation Example
66
Situation
  • A technician was observed performing routine
    maintenance on an ATR-42. He was closing out the
    aircraft during a Remain Over Night (RON) check
    following a RON work card. The work card listed
    the systems that needed to be checked but did not
    include instructions to switch the main battery
    off. The technician left the main battery switch
    on. Another more experienced technician was
    assisting him with closing the aircraft, and
    found the main battery switch on. He switched it
    off thereby correcting the first technicians
    error.


67
(No Transcript)
68
LOSA Observation Form
69
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

70
Form Section B.6 Close Up/Complete Restore
  • Error At Risk item 7 SERVICING PROCEDURES
    FOLLOWED
  • Threat codes
  • Information Mx/A4 (Inadequate)
  • Knowledge/Skills Mx/E5 (Task knowledge)
  • Mx/E8 (Aircraft system knowledge)
  • Effectively managed? ? Yes
  • Error Outcomes ? Inconsequential

71
Mx/A. Information (e.g. work cards, maintenance
manuals, service bulletins, maintenance
tips, non-routines, IPC, warning/signal,
etc.) Mx/A1. Not understandable Mx/A2. Unavailabl
e or inaccessible Mx/A3. Incorrect Mx/A4. Inadequa
te (e.g., missing graphics) Mx/A5. Uncontrolled
(e.g., outdated) Mx/A6. Too much conflicting
information Mx/A7. Update process is too long or
complicated Mx/A8. Incorrectly modified
manufacturers Maintenance Manual/Service
Bulletin Mx/A9. Information not
used Mx/A10. Other (explain below)
72
Mx/E. Knowledge / Skills Mx/E1. Technical
skills Mx/E2. Computer skills Mx/E3. Teamwork
skills Mx/E4. English proficiency Mx/E5. Task
knowledge Mx/E6. Task planning Mx/E7. Company
process knowledge Mx/E8. Aircraft system
knowledge Mx/E9. Other (explain below)
73
LOSA Observation Form
74
Additional Comments
They sent us one of the base mx guys because we
were short. He did bring the RON work card for
the close out. The work card listed the systems
that needed to be checked but did not have
instruction to secure the main battery switch.
The technician left the main battery switch on.
One of our senior line guys was also on the close
out and found the main battery switch on.
Nothing came of this but we would almost had a
dead aircraft in the morning.
When we have inexperienced mechanics we should
have a second set of eyes if we have the
manpower.
75
Practice Observations
76
Practice Observation Instructions
  • Please complete the appropriate section of the
    observation form for each of the following
    scenarios.
  • Identify and mark down the threats and errors and
    include any remarks.
  • Following your observation, enter your
    information into the Mx LOSA software database.

77
Scenario 1 Rag Left in Equipment Bay
78
Situation
  • A technician was in the aft equipment bay
    searching for fluid leaks of a CRJ-700. The LOSA
    observer noticed that a technician left a rag
    which was stuck in one of the control pulleys. A
    second technician found and removed the rag
    during the final check before closing the bay.


79
(No Transcript)
80
LOSA Observation Form
81
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

82
Form Section B.6 Close Up/Complete Restore
Your sheets and software entries should contain something similar to the following
  • Error At Risk item 5 Parts, materials, and
    wastes dispositioned
  • Threat codes
  • Individual Factors Mx/F9 (Memory Lapse forgot)
  • Environment/Facilities Mx/G19 (Restricted/confine
    d Work Area)
  • Effectively managed? ? Yes
  • Error Outcomes ? Inconsequential

83
Mx/F. Individual Factors Mx/F1. Physical health
(including hearing and sight) Mx/F2. Fatigue Mx/F3
. Time pressure Mx/F4. Peer pressure Mx/F5. Compla
cency Mx/F6. Body size/strength Mx/F7. Personal
event (e.g., family problem, car
accident) Mx/F8. Workplace distractions or
interruptions during task performance Mx/F9. Memor
y lapse (forgot) Mx/F10. Visual
perception Mx/F11. Assertiveness Mx/F12. Stress Mx
/F13. Situational awareness Mx/F14. Not properly
dressed (e.g., for weather) Mx/F15. Other
(explain below)
84
Mx/G. Environment / Facilities Mx/G8. Illuminat
ion Mx/G9. Wind Mx/G10. Jet blast Mx/G11. Vibratio
ns Mx/G12. Cleanliness Mx/G13. Hazardous or toxic
substances Mx/G14. Contaminated
surfaces Mx/G15. Power sources Mx/G16. Inadequate
ventilation Mx/G17. Slippery Mx/G18. Uneven work
surface Mx/G19. Restricted/confined work
area Mx/G20. Elevated work space
85
LOSA Observation Form
82
86
Additional Comments
Two mechanics came out for the first flight of
the day because of 'Fluid leak from APU.' The
Captain had the aft equipment bay door open
because he thought the leak was coming from the
ACM in the equipment bay, not the APU. One
mechanic entered the aft equipment bay and
tightened the moisture/condenser unit clamp to
the forward duct. The second technician handed
him some rags and went to retrieve the logbook,
because the aircraft was already boarded. When
the second technician came back, the first
technician told him to check the equipment bay.
The second technician found and removed a rag
during his final check.
The mechanic in the equipment bay did not do a
good enough check on his way out. The rag he left
behind was caught in one of the control pulleys
so this was not a small problem.
Final checks and accounting for all materials are
critical. This could have been a bad situation.

83
87
Scenario 2 MEL Violation
88
Situation
  • A line technician deferred inoperative ground
    power lights on an B737 aircraft which was
    allowed by the Minimum Equipment List (MEL).
    However he did not carry out the maintenance
    procedure that was required by the MEL to verify
    that the avionics vent fan warning horn was
    operative.

89
(No Transcript)
90
LOSA Observation Form
LOSA Observation Form
91
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

92
Errors and Threats
  • Error At Risk item 20 Maintenance action
    properly execute.
  • Threat codes
  • Information Mx/A9 (Information not used)
  • Organizational Factors Mx/H8 (Work
    process/procedure not followed)
  • Effectively managed? ? No
  • Error Outcomes ? Undesired state (A/C would have
    been dispatched in a non-airworthy condition)

93
Mx/A. Information (e.g. work cards, maintenance
manuals, service bulletins, maintenance tips,
non-routines, IPC, warning/signal,
etc.) Mx/A1. Not understandable Mx/A2. Unavailabl
e or inaccessible Mx/A3. Incorrect Mx/A4. Inadequa
te (e.g., missing graphics) Mx/A5. Uncontrolled
(e.g., outdated) Mx/A6. Too much conflicting
information Mx/A7. Update process is too long or
complicated Mx/A8. Incorrectly modified
manufacturers Maintenance Manual/Service
Bulletin Mx/A9. Information not
used Mx/A10. Other (explain below)
94
Mx/H. Organizational Factors Mx/H1. Quality of
internal support from technical
organizations (e.g., engineering, planning,
technical pubs) Mx/H2. Quality of external
support from technical organizations (e.g.,
manufacturer) Mx/H3. Company policies Mx/H4. Not
enough staff Mx/H5. Corporate change /
restructuring Mx/H6. Labor action Mx/H7. Work
process / procedure Mx/H8. Work process /
procedure not followed Mx/H9. Work process /
procedure not documented Mx/H10. Work group
normal practice (norm) Mx/H11. Team
building Mx/H12. Other (explain below)
95
LOSA Observation Form
LOSA Observation Form
96
Additional Comments
A line technician found that three of four ground
power lights were inop on test. He checked the
MEL in the Operating Manual for ground power
lights. He thought the power light was secondary
and that the aircraft was serviceable since only
the light function was out.
I told the line technician before he dispatched
the aircraft that he needed to complete the check
on the avionics vent fan horn. He was ready to
dispatch this aircraft with an illegal deferral.
All of the safety nets failed on this. I had to
intervene and have him do the checks before he
dispatched this unairworthy aircraft.
97
Scenario 3 Engine Oil Filler Cap
98
Situation
  • An inexperienced line technician was
    servicing oil on the right engine on a B737-800
    after engine shutdown. The technician was
    observed putting on the oil filler cap, but did
    not lock it down. A lead technician standing
    nearby saw that it was not locked and corrected
    the problem. The technician was unfamiliar with
    the cap.

99
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100
LOSA Observation Form
101
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

102
Form Section D. Servicing
  • Error At Risk item 18 CLOSE UP PROCEDURES
    FOLLOWED
  • Threat codes
  • Job/Task Mx/E1 (Technical Skills)
  • Effectively managed? ? Yes
  • Error Outcomes ? Inconsequential

103
Mx/E. Knowledge / Skills Mx/E1. Technical
skills Mx/E2. Computer skills Mx/E3. Teamwork
skills Mx/E4. English proficiency Mx/E5. Task
knowledge Mx/E6. Task planning Mx/E7. Company
process knowledge Mx/E8. Aircraft system
knowledge Mx/E9. Other (explain below)
104
LOSA Observation Form

105
Additional Comments
I was observing an inexperienced line technician
servicing oil on the right engine on a B737-800.
He waited two hours after engine shutdown so
there was no issue with drain down.
The technician didnt lock the oil filler cap
down. A lead tech saw that it was not locked and
showed the new tech what needed to be done.
This was a good example of a lead tech doing his
job by working with the inexperienced technician.
106
Scenario 4 757 Blind Oil Fill
107
Situation
  • The crew of a B757-200 that had been parked
    for over an hour called with the 2 engine EICAS
    showing only 12 quarts static at the gate.
    Because of time pressure, the lead technician had
    a line technician do a blind fill of 14 quarts of
    oil without running the engine first. This
    resulted in an overfilled oil reservoir.

108
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109
LOSA Observation Form
110
Threat Codes
  • Mx/A. Information
  • Mx/B. Equipment / Tools / Safety Equipment
  • Mx/C. Aircraft Design / Configuration / Parts
  • Mx/D. Job / Task
  • Mx/E. Knowledge / Skills
  • Mx/F. Individual Factors
  • Mx/G. Environment / Facilities
  • Mx/H. Organizational Factors
  • Mx/I. Leadership / Supervision
  • Mx/J. Communication
  • Mx/K. Quality Control
  • Mx/L. Other Contributing Factors

111
Errors and Threats
  • Error At Risk item 12 Documentation available
    and reviewed
  • Threat codes
  • Information Mx/A9 (Information not used)
  • Individual Factors Mx/F3 (Time pressure)
  • Error At Risk item 16 Proper cool down/drain
    down/temperature requirements observed
  • Threat codes
  • Individual Factors Mx/F3 (Time pressure)
  • Error At Risk item 17 Replenishment
    procedures followed
  • Threat codes
  • Organizational Factors Mx/H8 (Work
    process/procedure not followed, Mx/H10 (Work
    group normal practice norm)
  • Leadership/Supervision Mx/I6 (Other Lead
    instructed technician to act against procedure)
  • Effectively managed? ? No

112
Mx/A. Information (e.g. work cards, maintenance
manuals, service bulletins, maintenance tips,
non-routines, IPC, warning/signal,
etc.) Mx/A1. Not understandable Mx/A2. Unavailabl
e or inaccessible Mx/A3. Incorrect Mx/A4. Inadequa
te (e.g., missing graphics) Mx/A5. Uncontrolled
(e.g., outdated) Mx/A6. Too much conflicting
information Mx/A7. Update process is too long or
complicated Mx/A8. Incorrectly modified
manufacturers Maintenance Manual/Service
Bulletin Mx/A9. Information not
used Mx/A10. Other (explain below)
113
Mx/F. Individual Factors Mx/F1. Physical
health (including hearing and sight) Mx/F2.
Fatigue Mx/F3. Time pressure Mx/F4. Peer
pressure Mx/F5. Complacency Mx/F6. Body
size/strength Mx/F7. Personal event (e.g.,
family problem, car accident) Mx/F8.
Workplace distractions or interruptions during
task performance Mx/F9. Memory lapse
(forgot)
114
Mx/H. Organizational Factors Mx/H1. Quality of
internal support from technical organizations
(e.g., engineering, planning, technical
pubs) Mx/H2. Quality of external support from
technical organizations (e.g.,
manufacturer) Mx/H3. Company policies Mx/H4. Not
enough staff Mx/H5. Corporate change /
restructuring Mx/H6. Labor action Mx/H7. Work
process / procedure Mx/H8. Work process /
procedure not followed Mx/H9. Work process /
procedure not documented Mx/H10. Work group
normal practice (norm) Mx/H11. Team
building Mx/H12. Other (explain below)
115
Mx/I. Leadership / Supervision Mx/I1. Planning
/ organization of tasks Mx/I2. Prioritization of
work Mx/I3. Delegation / assignment of
task Mx/I4. Unrealistic attitude /
expectations Mx/I5. Availability of
supervision Mx/I6. Other (explain below)
116
LOSA Observation Form
116
117
Additional Comments
A flight crew called requesting oil service for
2 engine due to EICAS reading 7 quarts static.
The flight crew would not do a maintenance runs
so the lead technician had a line technician do a
blind oil fill. The line technician added 14
quarts. It did not generate a red alert automated
log in the maintenance computer. The crew ran the
engine for 10 minutes with no leaks or problems.
This was one of those few times when I had to
intervene as a LOSA observer. They checked the
level and fortunately it was within limits.
Another one of those times when nothing bad
happened but could have. We are heading down a
slippery slope with this type of norm.
114
118
This Concludes the Line Operations Safety
Assessment (LOSA) Maintenance (Mx) Operations
Line Training Scenarios
Visit the LOSA website www.MRLOSA.com
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